Reducing Myocardial Free Wall Rupture Following Acute
ST-Segment Elevation Myocardial Infarction: A Case for
Primary Angioplas

Myocardial free wall rupture (FWR) continues to be a dreadful complication of acute ST-segment elevation myocardial infarction (STEMI) occurring in about 1.3–2.5% of patients.1–3 FWR has been considered a significant cause of death in patients with STEMI following severe pump failure and arrhythmias4 and accounts for 8–17% of mortality in these patients.5 In the study by Nishiyama et al,1 FWR occurred in 1.3% of admitted patients with acute myocardial infarction and accounted for 13.3% of mortality in these patients, well within published data. Predictors of FWR after myocardial infarction (MI) include advanced age, female gender, unsuccessful reperfusion (complete occlusion or ineffective reperfusion) following treatment of the infarct-related vessel, lower body index, anterior MI and first acute MI.6–10 Diabetes has not been shown to be a predictor of FWR11 and data on hypertension is inconsistent.11,12 The etiology of FWR has not been well defined but it is probably a combination of mechanical, enzymatic and inflammatory factors imposed on a thinned and damaged myocardium.12 A complete and rapid reperfusion of the infarct-related artery is probably the strongest factor in the protection against FWR.3,8,9,13,14 Pharmacologic therapy such as beta-blockers and angiotensin converting enzyme inhibitors and avoidance of steroidal and non-steroidal anti-inflammatory drugs are also thought to be important preventative measures against FWR.15 Although successful reperfusion with thrombolytic therapy has been effective in reducing the incidence of FWR compared to conservative management or unsuccessful reperfusion,1,9 primary angioplasty (PA) appears to be more effective than thrombolysis, probably because of its ability to achieve a more predictable and complete reperfusion of the infarct-related vessel with a lesser chance of reocclusion.8,9,16–21 This is also in concordance with the data of Nishiyama and colleagues.1 In their study, thrombolytic therapy resulted in more FWR (1.6% vs. 0.5%, p

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